Richard Boyd
Robert J. Szczerba, Ph.D.
(Lockheed Martin Corporation)

Achieving a balance between human and computer can lead to “superhuman” healthcare.

We live in an exponential age, an age of increasing complexity and uncertainty. Aided by advancing computer power, often we create systems much more complex than our brains can process. It should not be surprising that, in an interconnected world of such complexity, we frequently see events spin out of our control and overwhelm us. Financial markets crash and digital viruses wrack the Internet. On the network-centric battlefield and in the technology-laden hospital we are asking humans to continuously adapt to enormously complex systems and perform flawlessly where the slightest mistake could lead to a preventable injury or death. As system complexity increases in critical domains, it becomes vitally important that we look for approaches that reduce the likelihood of human error and lower overall costs. We need to go beyond mere human capability.

One such approach is to leverage a process that combines the strengths of both man and machine to determine the best possible outcome. Engineers usually refer to this as the “mixed-initiative planning paradigm,” where both man and machine “negotiate” the best course of action in an iterative fashion. This is certainly not a new concept. The best chess player in the world is not a human, nor is it a computer, but a team of humans working with computers and perfected algorithms. The 21st century imperative would seem to be how to achieve the right balance between humans and automation to optimize outcomes. Those who do master this balance and achieve a comfortable fluency with simulation and analytics will not only outperform those who do not, but they will begin to appear superhuman.

Excellent examples of this concept come from the aerospace industry.  F-16 and F-35 fighter pilots have been trained to augment much of their sensory input and even make some decisions with the help of automated systems. This comfortable balance between pilot and automation results in a system capability that cannot be matched by other aircraft or pilots alone. These pilots often describe feelings of super-proprioception, achieving a continuous flow state where extraordinary feats are possible.

Can this concept also be used to improve the healthcare ecosystem?

There have been some improvements since a 1999 report released by the U.S. Institute of Medicine determined that medical errors in hospitals were causing close to 100,000 preventable deaths and one million injuries each year, but those efforts are trailing woefully behind advances in technology and there has been no measurable improvement. Additionally, a recent study of routine visits to 10 hospitals in North and South Carolina determined that patients have an 18 percent chance of being harmed by current medical practices.(i)  If there was an 18 percent chance of injury every time someone got into a car, how many people would drive? Yet, this error rate seems to be tolerated in healthcare. What is most distressing is that technologies and engineering approaches exist to dramatically diminish these errors, but they are not being used. Only recently, have surgeons started to use simple checklists to avoid mistakes in operating rooms. This process tool was integrated into aviation almost 100 years earlier.

Best-selling author Atul Gawande, both in his 2011 commencement address at Harvard Medical School and in his May 2011 article in The New Yorker, explained a central problem of medical practice today. He said that healthcare providers must learn a complex cooperative choreography akin to what pit crews perform during a Formula One race. He described how modern medical practice was designed during a time when there were very few medical interventions available to a practicing physician; therefore, it was conceivable for a single physician to hold himself forth as a master of all knowledge in the profession. He goes on to say that “Resistance…surfaces because medicine is not structured for group work.”(ii)  Yet, the increasing complexity of the 4,000 and growing surgical procedures and more than 6,000 drugs that a doctor is legally allowed to administer on a patient requires a cooperative team effort to avoid errors.

While healthcare struggles to adopt basic systems engineering practices, several other industries (such as aerospace and automotive) are adopting a new level of team integration: the integration of teams of humans in cooperation and symbiosis with automation.  Applying these practices to the healthcare industry may be the only hope for curtailing the escalating errors and costs. Thankfully, the models for this cooperation already exist, but will healthcare embrace them?

i A study of 10 North Carolina hospitals published in The New England Journal of Medicine in November 2010 (2010;363:2124-2134)
ii “Cowboys and Pit Crews” posted by Atul Gawande in The New Yorker, May 26, 2011